 <table border=0 cellpadding=2 width=100%>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_PREG_NR
	 </td>
     <td><input type='text' name='this_pregnancy_nr' size=10 maxlength=2 value='$TP_PNR'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $LDDate
	 </td>
     <td><!-- #154 -->
 		$TP_PREGDATE $TP_IMG_PDATE
		<FONT SIZE=-1  FACE='Arial' color='#000066'>
		$LDTime
	 <input type='text' name='delivery_time' size=10 maxlength=5 value='$TP_PTIME' >
 		</font></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_GRAVIDA
	 </td>
     <td><input type='text' name='gravida' size=10 maxlength=10 value='$TP_GRAV'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_PARA
	 </td>
     <td><input type='text' name='para' size=10 maxlength=10 value='$TP_PARA_VAL'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_GEST_AGE</td>
     <td><input type='text' name='pregnancy_gestational_age' size=10 maxlength=10 value='$TP_GAGE'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_NR_FETUSES
	 </td>
     <td><input type='text' name='nr_of_fetuses' size=10 maxlength=10 value='$TP_NFETUS'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_CHILD_ENR<br><font size=1>
	 $TP_SEPARATE
	 </font>
	 </td>
     <td><input type='text' name='child_encounter_nr' size=50 maxlength=60 value='$TP_CH_ENR'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_DELIV_MODE
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 $TP_DMODE_RADIOS
	 </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_ISBOOKED
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	$TP_ISBOOKED_YES
  	$TP_ISBOOKED_NO
	 </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_VDRL
	 </td>
     <td><input type='text' name='vdrl' size=10 maxlength=2 value='$TP_VDRL_VAL'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_RH
	 </td>
     <td><input type='text' name='rh' size=10 maxlength=2 value='$TP_RH_VAL'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>$TP_BPSYS
	 </td>
     <td><input type='text' name='bp_systolic_high' size=10 maxlength=10 value='$TP_BPSYS_VAL'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_BPDIAST
	 </td>
     <td><input type='text' name='bp_diastolic_high' size=10 maxlength=10 value='$TP_BPDIAST_VAL'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_PROTEINURIA
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 	$TP_PROT_YES
  	$TP_PROT_NO
	 </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_LABOUR_DUR
	 </td>
     <td><input type='text' name='labour_duration' size=10 maxlength=10 value='$TP_LABOUR_VAL'></td>
   </tr>

   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_INDUCT_METHOD
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 $TP_INDUCT_RADIOS
	 </td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_INDUCT_INDIC
	 </td>
     <td><input type='text' name='induction_indication' size=50 maxlength=60 value='$TP_INDUCT_VAL'></td>
   </tr>
 
    <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_ANAESTH
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 $TP_ANAESTH_RADIOS
	 </td>
   </tr>
	 
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_COMPLICATION
	 </td>
     <td><input type='text' name='complications' size=50 maxlength=255 value='$TP_COMPLIC'></td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_PERINEUM
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 $TP_PERINEUM_RADIOS
	 </td>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_BLOODLOSS
	 </td>
     <td><input type='text' name='blood_loss' size=10 maxlength=10 value='$TP_BLOSS'>
	 <select name='blood_loss_unit'>
	 $TP_BLOSS_OPTIONS
	</select>
	</td>
   </tr>
   <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_RETPLACENTA
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	$TP_RETPLACENTA_YES	 
	$TP_RETPLACENTA_NO	 
	</td>
   </tr>
    <tr bgcolor='#f6f6f6'>
     <td><FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_POST_LABOUR
	 </td>
     <td><input type='text' name='post_labour_condition' size=50 maxlength=60 value='$TP_PLABOUR'></td>
   </tr>
    <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_OUTCOME
	 </td>
     <td><FONT SIZE=-1  FACE='Arial'>
	 $TP_OUT_RADIOS
	 </td>
   </tr>
 
   <tr bgcolor='#f6f6f6'>
     <td><font color=red>*</font>
	 <FONT SIZE=-1  FACE='Arial' color='#000066'>
	 $TP_DOCBY
	 </td>
     <td><input type='text' name='docu_by' size=50 maxlength=60 value='$TP_DBY' readonly></td>
   </tr>
 </table>
